Clear Form
Form 2 – Applicant Report
Ministry of Community Safety
and Correctional Services
Pursuant to the Mandatory Blood Testing Act, 2006
and O. Reg. 449/07
TO BE COMPLETED BY THE APPLICANT
You may submit an application if:

you came into contact with a bodily substance of another person
and want to have their blood analysed for HIV/AIDS, Hepatitis B
or Hepatitis C; and

You came into contact with the bodily substance as a result of
being a victim of crime; while providing emergency health care
services or emergency first aid; or you fall under one of the
prescribed classes or circumstances (see section C).
You must deliver one copy of this form, together with a completed
Form 1 – Physician Report to the Medical Officer of Health in the
1
appropriate health unit . The application must be received by the
Medical Officer of Health no more than seven days after you came
into contact with the bodily substance (if the deadline falls on a
Saturday, Sunday or holiday, it shall be extended by one day).
If you submit an application under the Mandatory Blood Testing Act,
2006, you must consent to:
(a) The disclosure of the personal information and personal health
information related to the application to the Consent and
Capacity Board, if there is a hearing.
(b) Examination, counselling (including counselling respecting
prophylaxis or treatment), and baseline testing for HIV/AIDS,
Hepatitis B and Hepatitis C.
(c) The release by the police of any information from the police
report to the Consent and Capacity Board (where an
application is made as a victim of crime), in the event that the
application is referred to the Board.
If the form is not filled out completely or you fail to meet the
prescribed requirements, the application shall not proceed.
You will be notified within two days of this fact by the Medical
Officer of Health by registered mail.
If your application meets the requirements, the Medical Officer of
Health will disclose the details of the occurrence, as described in
this report and the physician report, to the respondent (the Medical
Officer of Health shall not reveal your personal information).
If the respondent does not comply with a request for voluntary
compliance and provide proof of such compliance, your application
will be referred to the Consent and Capacity Board for a hearing.
Hearings before the Consent and Capacity Board are public.
You must ensure that a valid copy of your baseline testing is
submitted to the Consent ad Capacity Board as soon as the
results are available. The Consent and Capacity Board may be
reached via fax at 416 924-8873 or 1 866 777-7273. Keep one
completed copy of this form and one completed copy of the
physician report for your own records.
A. Applicant Information
Collection, use and disclosure of the personal information on this form is for consideration of an application under the Mandatory Blood
Testing Act, 2006 requiring a respondent to give a blood sample to determine the HIV/AIDS, Hepatitis B and/or Hepatitis C status of the
respondent. The authority for collection and use of this information is the Mandatory Blood Testing Act, 2006. For information about
collection practices contact the Policy Development and Coordination Branch, Ministry of Community Safety and Correctional Services at
416 212-4221.
Applicant’s Full Name
Last Name
First Name
Middle Name
Applicant’s Address
Home Address
Unit Number
Place of Employment
Street Number
City/Town
Street Name
Province
Postal Code
Home Telephone
(
)
Ontario
OHIP Number (10 digits)
Version
Family Physician - if Different from Reporting Physician
Last Name
First Name
Unit Number
City/Town
Street Number
Sex
Age
Date of Birth (yyyy/mm/dd)
Middle Initial
Street Name
Province
Postal Code
Ontario
1
Male
Female
Business Telephone
(
)
Office Telephone
(
)
Office Fax Number
(
)
”appropriate health unit” means the health unit in the area where the respondent resides. For a list of health units and the areas they comprise, call the INFOline at
1-866-532-3161.
008-11-002E (2017/04)
© Queen's Printer for Ontario, 2017
Disponible en français
Next Page
Page 1 of 4
B. Identification of Respondent - The following information about the respondent is mandatory
Note: The respondent is the person whose bodily substances you may have come into contact with. If this form does
not include the name and address of the respondent, the application shall not proceed.
Respondent’s Full Name
Last Name
Full Address
Unit Number
First Name
Street Number
Middle Name
Street Name
City/Town
Province
Postal Code
Ontario
The following information about the respondent must be provided if known
Age
Date of Birth (yyyy/mm/dd)
Sex
Male
Female
Home Telephone
(
)
Business Telephone
(
)
C. Details of Occurrence - Date, time and location where you may have come into contact with a bodily
substance of the respondent
Date (yyyy/mm/dd)
Time
Unit Number
Street Number
Street Name
am
pm
City/Town
Province
Postal Code
Ontario
Describe the circumstances in which you may have come into contact with a bodily substance of the respondent
Describe any injuries you sustained
Did you take any precautions before (i.e. wearing gloves, goggles, mask, etc.) and after (i.e. immediately washing the exposed area) your
No
Yes, explain
contact with the bodily substance of the respondent?
008-11-002E (2017/04)
Next Page
Page 2 of 4
Please indicate under what circumstance you came into contact with a bodily substance of the respondent
1. As a result of being the victim of a
crime
Police officer as defined in the
Police Services Act, employee of a
police force who is not police
officer, First Nations Constable and
auxiliary member of a police force
2. While providing emergency health care
services or emergency first aid to the
person, if the person was ill, injured or
unconscious as a result of an accident
or other emergency
Firefighter, as defined in subsection
1 (1) of the Fire Protection and
Prevention Act, 1997
3. In the course of your duties, if you belong to
one of the following prescribed classes:
Paramedic and emergency medical
attendant, as those terms are
defined in the Ambulance Act
Person who is employed in a correctional
institution as defined in the Ministry of
Correctional Services Act, or in a place of
open custody or place of secure custody,
as those terms are defined in the Child
and Family Services Act
Member of the College of Nurses of
Ontario
Member of the College of
Physicians and Surgeons of Ontario
Special constable appointed under
section 53 of the Police Services
Act who is not employee of a police
force
4. While being involved in a prescribed
circumstance or while carrying out a
prescribed activity:
Paramedic student engaged in field
training
Medical student engaged in training
Nursing student engaged in training
“Victim of a Crime” means a victim of an alleged crime under the Criminal Code (Canada)
If your contact with the bodily substance of the respondent was as a result of being a victim of a crime, the following
information is mandatory:
Did you make a report to police about the
alleged crime?
Yes
No
Do you consent to the release by the police of
any information from the police report to the
Consent and Capacity Board, in the event the
application is referred to the Board?
Yes
Note: You must make a report to police if you are making an application
on the basis of being a victim of a crime and must consent to the
release by the police of any information from the police report to
the Consent and Capacity Board, in the event the application is
referred to the Board. Otherwise, the application is invalid and may
not proceed under the Mandatory Blood Testing Act, 2006.
No
Date Crime was Reported to Local Police Authorities
Occurrence Number
yyyy/mm/dd
Name and badge number of Police Officer to Whom Crime was Reported
Last Name
First Name
Badge Number
Police Service/Division/Detachment in which Crime was Reported
City
Province
Ontario
D. Additional Information – Provide any other information you believe may be relevant to the application,
including mental anguish, stress or anxiety exhibited as a result of the exposure occurrence.
008-11-002E (2017/04)
Page 3 of 4
Print Form
E. Consent to Examination, Counselling and Baseline Testing
I hereby consent to examination by the physician preparing the physician report which accompanies this form, to counselling (including
counselling respecting prophylaxis and treatment) and to baseline testing for the listed communicable diseases ordered by the reporting
physician.
Yes
No
Note: You must consent to examination, counselling and baseline testing. Otherwise, the application is invalid and
may not proceed under the Mandatory Blood Testing Act, 2006.
F. Treatment
Was Hepatitis B vaccine recommended
as a treatment for you?
Yes
No
Was HIV prophylaxis recommended
as a treatment for you?
Yes
No
I took the recommended Hepatitis B
vaccine
Yes
No
I took the recommended HIV
prophylaxis
Yes
No
Was HBIG recommended as a
treatment for you?
Yes
No
I am still taking this treatment
Yes
No
I took the recommended HBIG
Yes
No
Date I stopped treatment
- if applicable
yyyy/mm/dd
G. Consent to Disclosure of Personal Information
I hereby consent to the release of my personal information and personal health information related to this application to the Consent and
Capacity Board, in the event that the application is referred to the Board for a hearing called for the purposes of considering an order
requiring a respondent to give a blood sample to determine his/her HIV/AIDS, Hepatitis B and/or Hepatitis C status.
Yes
No
Note: You must consent to the release of your personal information and personal health information to the Consent
and Capacity Board. Otherwise, the application is invalid and may not be considered under the Mandatory Blood
Testing Act, 2006.
H. Information Accurate
I hereby confirm that the information provided in this form is accurate to the best of my knowledge.
Name of Applicant - please print
Last Name
Signature
First Name
Middle Initial
Date (yyyy/mm/dd)
Print Form
008-11-002E (2017/04)
Page 4 of 4